Of more than half a million persons suffering from end stage renal disease (ESRD) in the United States, nearly one-third are black, and the relative incidence of ESRD among blacks is 3.6-times higher than that among whites. In a study of 1.3 million incident ESRD patients, we recently showed that black patients under 50 die on dialysis at up to twice the rate of their white counterparts. We hypothesize that the increased dialysis mortality specific to younger black patients results from racial differences among several interacting components: the biology of renal failure, socioeconomic status (SES) and access to healthcare, and center and network-level factors. Characterizing the underlying mechanisms is critical to improve survival in this population. In an effort to better understand the mechanisms underlying increased mortality for young black patients on dialysis, we propose: 1. To identify subgroups of young ESRD patients in whom racial disparities in dialysis survival are attenuated or amplified, 2. To identify multilevel predictors of reduced survival for younger black patients, and 3.To identify additional factors not captured in the national registry that might explain racia disparities in dialysis survival. The fellowship applicant aspires to become an academic nephrologist, dividing her time between research and patient care. She aspires to use epidemiologic and statistical methods to better understand the mechanisms underlying disease processes and to quantify the effects of treatments, practices, and policies on patient health, with the hope of improving providers' and patients' ability to make informed, evidence-based decisions. Under this fellowship she hopes to complete a combined MD and PhD in epidemiology, which will allow her to build a strong methodological foundation and afford her protected time to produce an integrated body of work addressing a complex research question, facilitating her transition from guided researcher to independent investigator. Specific goals for this fellowship include: 1. Gain exposure to clinical nephrology, 2.Gain exposure to clinical transplant, 3. Achieve a strong foundation in clinical epidemiologic methods, 4. Attain proficiency in advanced statistical methods and further develop statistical programming skills, 5. Enhance skills in scientific discourse and master effective oral and written presentation of scientific findings, 6. Gain experience in the development, conduct, and maintenance of longitudinal cohort studies, 7. Learn to coordinate a multidisciplinary research team, and 8. Develop skills to become an independent investigator. At the start of the funding period, the applicant will be entering her second year of medical training at the Johns Hopkins University School of Medicine. She has already completed a masters' degree in epidemiology at Johns Hopkins, and has spent the past 4 years pursuing epidemiologic research full-time in the Johns Hopkins Department of Surgery, under the mentorship of Dr. Dorry Segev, the sponsor of this fellowship. PUBLIC HEALTH RELEVANCE: The proposed research seeks to understand the mechanisms underlying disparities in dialysis survival for younger black patients with end-stage renal disease. Patient, center, and regional factors and potential interactions between them will be explored using a variety of epidemiologic approaches. The results will be critical for informing interventions to improve survival in this population.